Childhood Trauma   Heather Forkey, M.D.
Child Trauma   Trauma has very obvious   physical effects.   Trauma has significant   mental and   developmental effects.  ...
History of Trauma
What Does Trauma Look Like?    How does brain develop?    How does trauma impact that brain’s development?    Why are chil...
History and Review of Systems          Trauma’s influence on brain results impacts bodily functions.                    Res...
History and Review of Systems                        Response to Trauma: Behaviors       Category      More Common With   ...
History and Review of Systems                  Exposure to trauma impacts development and school functioning.             ...
Identifying Trauma                                        Medical Analogy: Tuberculosis                     Tuberculosis  ...
Case: 38-month-old Child (JG)  Foster mother is concerned about JG’s behavior.  Severe tantrums.     Hurts other children ...
Case: 16-year-old Youth (EM)Male who recently had a fight with his stepfather.     Ended in police involvement.Diagnosed wi...
Discussion of Cases                      Next
Next
How To Screen Physician can probe for information about toxic stressors in a non- threatening, but trauma informed manner....
Open Ended Questions    These questions may prompt the family to remember         stressors they might not have thought to...
Direct Questions       When trying to identify domestic violence, substance        abuse, bullying or child abuse, one may...
Formal Screening Tools                                             Very useful for most objective data.                   ...
How to Respond       Scripts       Anticipatory Guidance       Referrals: Trauma Specialists
Scripts   Step One: Describe Pathophysiology of Trauma Response                               Our bodies are designed to h...
Scripts   Step Two: Help Caretaker Recognize Feeling of Trauma   Parents and older children should be prompted to recall a...
Scripts          Step Three: Help Caretaker Extrapolate Own             Experience to Situation of Toxic Stress   Parents ...
Scripts                      Step Four: Brain Response When trying to learn piano, one plays the same piece over and over....
Anticipatory Guidance    Lower tone and intensity of voice.       Come down to child’s level.       Help child avoid a str...
Anticipatory Guidance                                  Part OneWhat you will see:          Traumatized children will respo...
Areas of the brain responsible for recognizing andresponding to threat are turned on, hypertrophied.             How do yo...
Do not take these behaviors personally.                                          Next
Anticipatory Guidance                             Part Two What you will see:             Traumatized children are more li...
Brain does not recognize that this new situation does not                contain the same threats.                How do y...
Helping the child interpret your face or voice tone willhelp avoid the child escalating in situations that otherwise      ...
Anticipatory Guidance                                  Part ThreeWhat you will see:              Traumatized children need...
- Responding with aggression trigger which will put the          child’s brain back into threat mode.- Logic centers shut ...
- Avoid yelling anddemonstrating aggression.- Lower the tone andintensity of voice.- Come down to the child’slevel.- Keep ...
Anticipatory Guidance                                   Part FourWhat you will see:               Traumatized children do ...
Relaxation, breathing techniques, and yoga all stimulate       parts of the brain which help it to reorganize synapses    ...
- Develop breathing techniques, relaxation skills, orexercises which the child can employ when getting upset.- Guide the c...
Anticipatory Guidance                                   Part FiveWhat you will see:             Traumatized children will ...
- Children come with negativebeliefs and expectations aboutthemselves and about caregivers.- Reenactment or recreating old...
- Provide disconfirming messages that say child is safe,wanted, capable and worthwhile and that caretaker isavailable, reli...
Referrals    Referrals should be to trauma specific therapies if they are available.    For young children: Know More      ...
Young Children 0-5 Years OldGOALS:     Work with caregivers and    children to address child    behaviors observed during ...
Older Children 5+ Years OldGOALS:   Trains children and families in:     Relaxation techniques.     Skills and language to...
Coding  Office Visit Codes:  (can use in combination with well-child visit code if criteria for BOTH a well-  child and pro...
CodingDiagnosis Codes (ICD-9)Physical Symptoms564.00           Constipation                                  Development a...
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Trauma Project

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  • Trauma responses are adaptive and protective when children are in a threatening situation. Behaviors which are adaptive in settings of threat can persist when children are removed from the stressor, and then these same responses appear maladaptive. When not put into the context of the traumas experienced they can be interpreted as pathologic.\n
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  • Trauma inhibits development of the hippocampus and prefrontal cortex in the brain- areas responsible for executive function which is composed of working memory, inhibitory control, and cognitive flexibility. These are the skills required to learn, function in social settings, and stay focused. They allow us to display self-control, stay on task despite distractions and hold one idea in our minds as we learn the next step in the process. These skills develop through practice and are strengthened by experiences.\n
  • Physicians caring for children who have experienced toxic stressors should assume child will be affected until proven otherwise. Children should all be screened as they would after exposure to infection such as tuberculosis. Look over the chart to see the similarities between a disease such as Tuberculosis compared to trauma.\n
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  • To begin to screen for trauma, there are certain questions the physician can ask that provide a prompt for what family members may have forgotten or are unsure what the physician would want to know. Look through these then click back to view more direct questions to ask.\n
  • Using what we know about trauma responses of the body and behavior, the physician can easily lay out concerns with questions such as these. Read through the two shown, then click back to view formal screening tools.\n
  • Trauma screening tools can be used to objectively determine if trauma symptoms are present. The UCLA PTSD-RI is a tool to identify symptoms of PTSD, but requires children or families to know what the specific trauma is, and can take up to 30 minutes to administer.\nThere is an abbreviated version which is useful for identifying symptoms of trauma and can be administered quickly in the office setting.\nThe Trauma Symptom checklist is completed by caregivers for young children, and children themselves when over age 8. It is more inclusive and specific for identification of symptoms in children than the abbreviated UCLA test, but must be purchased for office use, and can cost up to $2.00 per patient.\n\nLook over the chart of formal screening tools to familiarize yourself with the different types of tools. When completed, you can click back to review ways to screen again or press next to continue with the presentation.\n
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  • Once you have affirmation that the trauma response is a healthy response to an unhealthy threat through the child’s symptoms, you can use the following scripts to help the caretaker further understand and help the child.\n
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  • Children and families trying to manage trauma in their lives need the lives need the help of mental health providers trained specifically in trauma sensitive and specific therapies. Referrals should be to trauma specific therapies. To know more about therapies for the age groups, click on “know more.”\n
  • It is NOT true that nothing is available for young or even preverbal children. PCIT and CPP are for children aged 0-5 and work with caregivers and children to address child behaviors observed during play, to teach caregivers to understand the impact of trauma and how best to respond.\n
  • Trauma therapies start with training children in relaxation techniques, skills, and language to access emotions and some psychoeducation about what has happened to them. When children and families have the emotional modulation skills to safely address the trauma, the child is guided to create a trauma narrative. This allows the child to develop a story about what happened to them. When the child is able to tell or read this story to their caregiver it indicates the trauma no longer defined the child, but is instead a story of what happened to them, having lost its power to continue to harm.\n
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  • Trauma Project

    1. 1. Childhood Trauma Heather Forkey, M.D.
    2. 2. Child Trauma Trauma has very obvious physical effects. Trauma has significant mental and developmental effects. Next
    3. 3. History of Trauma
    4. 4. What Does Trauma Look Like? How does brain develop? How does trauma impact that brain’s development? Why are children’s responses variable? Impacts on mental health. Impacts on development. Impact on health for lifespan. Next
    5. 5. History and Review of Systems Trauma’s influence on brain results impacts bodily functions. Response to Trauma: Bodily Functions Function Central Cause Symptom 1. Difficulty falling asleep. Stimulation of reticular Sleep 2. Difficulty staying asleep. activating system. 3. Nightmares. 1. Rapid Eating. Inhibition of satiety center, Eating 2. Difficulty staying asleep. anxiety. 3. Food hoarding. 1. Constipation. Increased sympathetic tone, Toileting 2. Lack of satiety. increased catecholamines. 3. Enuresis. Next
    6. 6. History and Review of Systems Response to Trauma: Behaviors Category More Common With Response Misidentified As - Females - Detachment - Depression - Young Children Dissociation - Numbing - Inattentive ADD - Ongoing trauma/ (Dopaminergic) - Compliance - Developmental pain - Fantasy Delay - Inescapable/Helpless - ADHD - Hyper vigilance - Males - ODD - Aggression Arousal - Older Children - Conduct Disorder - Anxiety (Adrenergic) - Observer - Bipolar Disorder - Exaggerated - Able to act - Anger Management Response difficulties Next
    7. 7. History and Review of Systems Exposure to trauma impacts development and school functioning. Response to Trauma: Development and Learning Impact on Working Impact on Inhibitory Impact on Cognitive Age Memory Control Flexibility Frequent severe Difficulty acquiring tantrums. Infant / developmental Easily frustrated. Toddler milestones. Aggressive with other children. Difficulty with school skill acquisition. Frequently in trouble Organizational Difficulties. School Aged Losing details can lead at school and with Child to confabulation, peers for fighting and Can look like learning problems or ADHD. viewed by others as disrupting. lying. Next
    8. 8. Identifying Trauma Medical Analogy: Tuberculosis Tuberculosis Trauma Not every child develops disease. Not every child exposed develops symptoms. Some exposed will be unaffected, some will develop Some exposed will be unaffected, some will develop latent disease, some will become acutely ill. latent disease, some will become acutely ill. All children exposed should have a PPD. All children exposed should have screening. If trauma screening positive, should have full trauma If PPD positive, should have CXR. assessment. Specific treatments are available and effective. Specific treatments are available and effective. Next
    9. 9. Case: 38-month-old Child (JG) Foster mother is concerned about JG’s behavior. Severe tantrums. Hurts other children and damages furniture. Very short attention span, does not follow directions. BMI > 95% Wants to eat all the time. Obese. Limited vocabulary. Not toilet trained. Insomnia. Next
    10. 10. Case: 16-year-old Youth (EM)Male who recently had a fight with his stepfather. Ended in police involvement.Diagnosed with ADHD 3 years ago.Increased aggression 18 months ago.Diagnosed with bipolar disorder 1 year ago.Trouble with insomnia.Frequent headaches- some are severeand associate with nausea and photophobia.Medications: Concerta, Tenex, Clonidine Next
    11. 11. Discussion of Cases Next
    12. 12. Next
    13. 13. How To Screen Physician can probe for information about toxic stressors in a non- threatening, but trauma informed manner. Open Ended Questions to Ask In the case that the physician may need to be more direct, use what they know about how the body responds to lay out concerns. More Direct Questions to Ask Formal Trauma Screening Tools
    14. 14. Open Ended Questions These questions may prompt the family to remember stressors they might not have thought to tell the physician. “Do you know of any really scary or upsetting things that have happened to you (your child) before he/she came to live with you?” “Since the last time I saw you (your child) has anything really scary or upsetting happened to you (your child) or anyone in your family?” Back
    15. 15. Direct Questions When trying to identify domestic violence, substance abuse, bullying or child abuse, one may have to be more direct. “You have told me that your child is having difficult with aggression, attention and sleep. Just as fever is an indication the body is dealing with an infection, when these behavioral symptoms are present, they indicate that the brain and body are responding to a stress or threat. Do you have any concerns that your child is being exposed to threat?” “The behaviors you describe and the trouble she is having with school and learning are often warning signs that the brain is trying to manage stress or threat. Sometimes children respond this way if they are being harmed, or if they are witnessing other they care about being harmed. Do you know of violence exposure at school, with friends, or at home?” Back
    16. 16. Formal Screening Tools Very useful for most objective data. Trauma Screening Tools Number of Admin and Cultural Cost and Tool Description Items and Age Group Scoring Time Considerations Developer Format Assesses Child and 20-30 min to UCLA PTSD-RI: 20-22 items Available to Intl. exposure to Parent: 7-12 administer English Post Traumatic depending on Soc. for trauma and years Stress Disorder child, parent, or Traumatic Stress impact of 5-10 min to Spanish Reaction Index youth version. members. events. Youth 13+ score Available to Intl. Elicits trauma 9 items for child 8-16 years English Abbreviated Soc. for related 2-5 minutes UCLA PTSD RI Traumatic Stress symptoms. 6 items for adult 3-12 years Spanish members. TSC-C: 54 items TSC-C Trauma Elicits trauma TSC-YC: 90 8-16 years English Symptom Proprietary related items, caregiver 15-20 minutes Checklist for ($168 per kit) symptoms. report for young 3-12 years Spanish Children children Back Next
    17. 17. How to Respond Scripts Anticipatory Guidance Referrals: Trauma Specialists
    18. 18. Scripts Step One: Describe Pathophysiology of Trauma Response Our bodies are designed to help us survive in the wilderness where the ability to respond to threat, such as a hungry tiger, is required to protect our bodies. Our bodies and brains are designed so that at times of threat the brain is intent on fighting, running, or hiding. NOT on learning or remembering the facts about the event. These responses are supposed to be strong, but short lived, and following the threat the body is designed to Part Two
    19. 19. Scripts Step Two: Help Caretaker Recognize Feeling of Trauma Parents and older children should be prompted to recall a time when they felt threat (car accident, fight, victim of crime) and remember how their bodies felt. The heart raced and their muscles were ready to go. While they may remember acutely the minutes before the accident or threat, they may have little recollection of the actual frightening event. Part Three
    20. 20. Scripts Step Three: Help Caretaker Extrapolate Own Experience to Situation of Toxic Stress Parents are guided to imagine the experience of living in a situation where “the tiger” is in the house. This causes the fight, flee, or hide response, but instead of having the chance to return to baseline following a short lived threat, the feeling stays. Part Four
    21. 21. Scripts Step Four: Brain Response When trying to learn piano, one plays the same piece over and over. Eventually the brain connections are so strong, fingers practically play the piece by themselves, no need to think. Response to trauma is the same. Once the connections are made and reinforced, little stimulation causes strong response. Parts of the brain dedicated to responding to trauma hypertrophy and grow connections. Parts of the brain used in learning and logic are pruned away and get smaller. States become traits. Back
    22. 22. Anticipatory Guidance Lower tone and intensity of voice. Come down to child’s level. Help child avoid a stress response. Help child interpret your facial or vocal tones. Relaxation, breathing exercises, and yoga will promote calm behavior. Next
    23. 23. Anticipatory Guidance Part OneWhat you will see: Traumatized children will respond to anything perceived as threat more quickly and more forcefully than other children. Why does this occur?? Answer
    24. 24. Areas of the brain responsible for recognizing andresponding to threat are turned on, hypertrophied. How do you Respond?? Answer
    25. 25. Do not take these behaviors personally. Next
    26. 26. Anticipatory Guidance Part Two What you will see: Traumatized children are more likely to misread facial and non-verbal cues and perceive threat where none is intended. Why does this occur?? Answer
    27. 27. Brain does not recognize that this new situation does not contain the same threats. How do you Respond?? Answer
    28. 28. Helping the child interpret your face or voice tone willhelp avoid the child escalating in situations that otherwise seem innocuous. Next
    29. 29. Anticipatory Guidance Part ThreeWhat you will see: Traumatized children need to be redirected or behavior starts to escalate. Why does this occur?? Answer
    30. 30. - Responding with aggression trigger which will put the child’s brain back into threat mode.- Logic centers shut down, fight, flight or hide response takes over. How do you Respond?? Answer
    31. 31. - Avoid yelling anddemonstrating aggression.- Lower the tone andintensity of voice.- Come down to the child’slevel.- Keep directions devoid ofstrong emotion. Next
    32. 32. Anticipatory Guidance Part FourWhat you will see: Traumatized children do not have skill set for self- regulation or for calming down once upset. Why does this occur?? Answer
    33. 33. Relaxation, breathing techniques, and yoga all stimulate parts of the brain which help it to reorganize synapses and cells and promote calm and centered behavior.How do you Respond?? Answer
    34. 34. - Develop breathing techniques, relaxation skills, orexercises which the child can employ when getting upset.- Guide the child at first then just use the skills whendistress starts to appear. Next
    35. 35. Anticipatory Guidance Part FiveWhat you will see: Traumatized children will challenge caretaker, often in ways that threaten placement. Why does this occur?? Answer
    36. 36. - Children come with negativebeliefs and expectations aboutthemselves and about caregivers.- Reenactment or recreating oldrelationships with new people toevoke same reactions in caretakersthat children experienced with otheradults, and lead to familiar reactions.- These patterns helped childrensurvive in the past, prove negativebeliefs, help child vent frustrationand give child some sense ofmastery. How do you Respond?? Answer
    37. 37. - Provide disconfirming messages that say child is safe,wanted, capable and worthwhile and that caretaker isavailable, reliable and responsive.- Praise even neutral behavior.- Be aware of own emotional responses to child’sbehavior.- Correct when necessary in calm, unemotional tone.- Repeat, repeat, repeat.- Do not take these behaviors personally. Back
    38. 38. Referrals Referrals should be to trauma specific therapies if they are available. For young children: Know More PCIT: Parent Child Interactive Therapy CPP: Child Parent Psychotherapy For older children: Know More TF-CBT: Trauma Focused Cognitive Behavioral Therapy CBITS: Cognitive Behavioral Intervention for Trauma in Schools Next
    39. 39. Young Children 0-5 Years OldGOALS: Work with caregivers and children to address child behaviors observed during play. Teach caregivers to understand the impact of trauma and how best to respond. Back
    40. 40. Older Children 5+ Years OldGOALS: Trains children and families in: Relaxation techniques. Skills and language to access emotion. Psychoeducation. Child is guided to create a trauma narrative. Child develops a story about what happened to them. Final goal: Child is able to tell or read story. Back
    41. 41. Coding Office Visit Codes: (can use in combination with well-child visit code if criteria for BOTH a well- child and problem oriented visit are met) 99201-99205 (initial) 99211-99215  (follow-up)   Consult Visit Codes: 99241-99245 (initial)   Screening Codes  (must document results in chart) 96110: Developmental Screening (including parent/caregiver completed forms/ rating scales   When using office visit code  and screening code  at same encounter,  add  -59 modifier to visit/consult code and -25 modifier to screening code Health and Behavior Assessment/Intervention 96150: initial face to face assessment including health focused clinical interview, behavioral observations, health oriented questionnaire, psycho-physiolgoical monitoring. Billed in 15 minute increments 96151: reassessment 96152 health and behavior intervention; each 15 minutes face to face.   Case Management (non-facetoface)   99339:  physician supervision of patient in home/domiciliary requiring complex and multidicsciplinary care, development and/or revision of care plans, review of patient status/reports, studies, communication/calls for purpose of assessment  or care decisions with health care providers,  family/surrogate.  15-29 minutes per calendar month   99340: 30 minutes or more Next
    42. 42. CodingDiagnosis Codes (ICD-9)Physical Symptoms564.00 Constipation Development and Cognitive Function787.6 Encopresis NOS 781.99 Abnormalities of the nervous, muscle or nervous system788.30 Enuresis-NOS 799.54 Frontal lobe/executive function deficit783.41 Failure to thrive 783.40 Lack of normal physiologic development (developmental delay)783.3 Feeding difficulty 319 MR-severity unspecified760.71 FAS/FAE 799.59 Other signs/symptoms with cognition263.1 Malnutrition- mild263.2 Malnutrition -moderate263.3 Malnutrition- severe742.1 Microcephaly765.10 Prematurity760.70 Prenatal exposure-unspecified780.50 Sleep disturbance NOSEmotional/Behavioral Symptoms995.52 Abuse/neglect309.9 Adjustment disorder NOS300.00 Anxiety NOS314.01 ADHD combined type (can add inattentive vs impulsive/hyperactive)313.89 Attachment disorder799.51 Attention problem - not ADHD312.81 Conduct disorder312.9 Conduct disturbance/disruptive behavior- unspecified311 Depression799.25 Demoralization/apathy799.24 Emotional lability314.9 Hyperkinetic -unspecified799.23 Impulsiveness799.22 Irritability799.21 Nervousness300.3 OCD313.81 ODD799.29 Other signs/symptoms of emotional state309.81 PTSD
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